JDO
Scholarship Application
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Roxbury Multi Service Center, Inc.
John D. O’Bryant Education Center Scholarship
Application Form 2015
The following information must be on file before your application is considered complete: (Please use the
following as a checklist to ensure that all documents are submitted)
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Application Form (Handwritten, faxed or emailed applications will not be accepted)
Official high school transcript
Signed copy of Acceptance Letter from school you plan to attend
Two (2) Recommendation Letters, One (1) on official organization letterhead
Copy of 2015-2016 school cost (tuition, books, supplies)
Complete copy of Student Aid Report (SAR) – all pages
Copy of Financial Aid Award letter for the college or university you plan to attend
Disclosure of all pending scholarships
Short Personal Essay- max 1000 words (must be typed)
This application and all documentation must be submitted to RMSC-JDO Scholarship Committee by May 15, 2015
Mail to: John D. O’Bryant Education Center
c/o Roxbury Multi-Service Center, Inc.
434 Warren Street, Boston, MA 02121
Attention: Carole Montgomery
A.
PERSONAL INFORMATION
Social Security Number
Name
Home Address
First
Middle
Last
Street
City
State
Zip Code
Mailing Address (if different)
Telephone
Best time to call:
Date of Birth
Place of Birth
Country of Citizenship
If not a U.S. citizen, are you a Permanent resident?
Race/Ethnicity
Male
Female
Email Address: ________________
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Scholarship Application
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B.
ACADEMIC INFORMATION
High School
Name
Completion Dates
Program Name
Academic Standing
or Rank
Address
General Equivalency Diploma
Organization Name
Address
Home Study –Certifying Organization
Name
Address
Please list any academic awards or honors you have received:
If school of choice changes after the deadline, please forward acceptance letter as soon as possible. Please indicate
the current status of your college application(s):
Name of College/University
1.
2.
3.
4.
Admission Status – indicate school of choice with an (*) asterisk
Accepted
Denied
Pending
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Scholarship Application
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5.
6.
C.
EXTRA-CURRICULAR ACTIVITIES/COMMUNITY/VOLUNTEER SERVICE
Organization
1.
2.
3.
4.
5.
D.
Beginning
Dates
Ending
Position Held
#Hours/Week
PERSONAL ESSAY
Please attach a short essay (maximum 1000 words) on the personal or career goals you have set for yourself. (Must be
typed)
E.
SCHOLARSHIP INFORMATION
List all other scholarships, grants/loans for which you have or will apply for this year:
Application Status
Decision Status
Scholarships/Grants/Loans
Applied
Will Apply
Approved
1.
2.
3.
4.
5.
6.
Denied
If any award (scholarship/grant/loan) has been refused, please explain the reason(s) for refusal. Prior to any awards of
monies a final update must be submitted to scholarship committee.
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Scholarship Application
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Please attach two (2) reference letters. The two letters should be a combination of a community leader, teacher, clergy,
supervisor, and/or adult mentor. This person should know of your academic abilities, be familiar with your character and your
ability to set and meet goals and overcome challenges.
By signing below, I affirm that all information contained on this application is true and accurate to the best of my knowledge. I
also fully recognize that any misrepresentations found on this form may result in me being declared ineligible for a scholarship
award. An application is INCOMPLETE without your signature.
Signature
Date
*DID YOU SUBMIT ALL PERTINENT DOCUMENTS? - PLEASE UTILIZE THE CHECKLIST AT THE BEGINNING*